Healthcare Provider Details

I. General information

NPI: 1619004421
Provider Name (Legal Business Name): PULMONARY MEDICINE & INFECTIOUS DISEASE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD SUITE 2308
SAN DIEGO CA
92120-5244
US

IV. Provider business mailing address

6699 ALVARADO RD SUITE 2308
SAN DIEGO CA
92120-5244
US

V. Phone/Fax

Practice location:
  • Phone: 619-462-9010
  • Fax: 619-287-8165
Mailing address:
  • Phone: 619-462-9010
  • Fax: 619-287-8165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. EDWARD C FEDERMAN
Title or Position: PARTNER
Credential: M.D.
Phone: 619-462-9010